One conclusion drawn from the 2018 midterm elections is health care is a big deal for Americans. In fact, according to pre- and post-election polling, health care may be the biggest deal, as a plurality of voters identified health care as their top issue in casting their vote.  

Concerns about health care—in particular, the Affordable Care Act (ACA)—may have helped propel Republicans in 2016 into the White House and to majority control in the US House and Senate.

Conversely, the US House of Representatives—the body that voted 217 – 213 in 2017 to nearly repeal the ACA—saw its Republican majority become a 199 – 235 minority for 2019, a loss of 40 seats to the Democrats (one race in North Carolina has not been called). Most House Democrats campaigned on protecting popular features of the ACA, especially the protection of coverage for pre-existing conditions.

Meanwhile, Republicans in the US Senate, which failed to approve an ACA-repeal proposal, increased their majority to 53 – 47. Any partisan health care proposals coming over from the House will surely be met with an equally partisan response.

At the state level, Democrats picked up seven governorships across the country, resulting in 23 states led by Democrats, 27 states led by Republicans.

So what can we make of this, now more than two months after the November 6 midterm elections? As the elected prepare to take office, we can look at pre- and post-election actions and statements to suggest possibilities.

ACA Revisited…Again

For nearly a decade, the ACA and its major components have dominated health care policy debates at the federal and state levels. That could continue going into the 2020 elections, given the contrast between President Donald Trump’s major promise to repeal the ACA and most Democrats’ commitment to preserve and protect it. But the President’s comments at a post-midterms news conference indicate he is willing to compromise with Democrats on health care legislation.

The level of attention given to the ACA in the new Congress could hinge on the outcome of Texas v. United States in the Northern District of Texas, which challenges the constitutionality of the ACA’s individual mandate. The recent decision for the plaintiffs, representing 20 states, could lead to the further unraveling of the ACA. The US Justice Department under the Trump Administration declined to defend the ACA in the case.

Democrats’ focus on pre-existing conditions protections in the midterms was responsive to Republican efforts to undo the ACA, including the Trump Administration’s administrative rulemaking, which enabled expansion of association and short-term health plans. The plans are free of some ACA requirements, such as providing coverage of pre-existing conditions.

The new Democrat majority in the House is expected to advance legislation protecting coverage for pre-existing conditions and force Republicans to go on record with a vote on the issue. Late in 2018 campaigning, President Trump and Republicans at both federal and state levels promised action affirming protection of pre-existing conditions coverage, so a bipartisan compromise could be forthcoming.

House Democrats could also try to place restrictions on the sale of short-term health plans that don’t include elements of the ACA.

Medicare for All

Several Democrats in the House joined a caucus dedicated to making Medicare available to all Americans. Many in the caucus are running for House leadership positions, though there are doubts about whether even the majority of House Democrats would support a “Medicare for All” proposal. Democrat alternatives providing a more limited expansion of Medicare, such as to Americans as young as age 50, are seen as having a better chance. Neither Senate Republicans nor President Trump would support either Medicare proposal, but House Democrats could advance the legislation anyway as a marker for the 2020 elections.

Prescription Drug Pricing

Newly-elected Speaker Nancy Pelosi said following the mid-term elections that lowering the cost of prescription drugs was a top priority for Democrats. And since President Trump has also made reducing drug pricing a priority, Democrats and Republicans could find an opportunity to advance a bipartisan bill. The President has already signed legislation to improve patient access to drug pricing information at the pharmacy, and in October he proposed new rulemaking that would lower the cost for certain expensive drugs by requiring Medicare to base its payments on the lower prices paid in other countries for the same drugs.

Medicaid Expansion Under the ACA

The increase in Democrat governorships will likely result in more states expanding Medicaid eligibility. Thirty-seven states including the District of Columbia expanded Medicaid eligibility under the ACA, according to a new Kaiser Family Foundation report. The total includes Idaho, Nebraska and Utah, which approved expansion measures on the November 6 ballot but have yet to implement the decision. On the flip side of the issue, Montana voters rejected a November 6 ballot measure that would have extended the state’s expansion authority. As a result, the expansion in that state will sunset on June 30, 2019, unless the state’s Legislature acts to extend it.

Medicaid Work Requirements

The Trump Administration approved waivers in five states requiring certain Medicaid beneficiaries to meet work requirements to receive Medicaid benefits. Additional states could seek similar approvals, though the new Democrat governors are unlikely to do so.

Heading into the new Congressional term, it is clear that campaigning for 2020 has already begun. No health care proposal will advance without extensive consideration for how it will impact candidates’ election prospects.